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Tracy works as the risk manager at ABC Medical Center, a 300-bed urban teaching facility. One morning, she receives a call from Jerry, the surgical director, asking her to come immediately to one of the operating rooms where a patient was scheduled for a right foot amputation.

As Tracy approaches the operating room, she goes over the preoperative care that is required for all patients undergoing surgery. The patient’s identification, verification of the involved limb, and the time out procedure are all in place.

Tracy walks into the operating room and immediately notices the concern on the faces of the medical and nursing staff. The Medical Director goes on to explain why the call was made: the patient’s wrong limb had been surgically removed.

Tracy must now complete a series of notifications because this is a serious reportable event (SRE). To remain in compliance with state and Joint Commission requirements, who must be notified, and what follow-up process must be completed?


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